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Regulated Medical Waste PagaRAcD�NGDOCUMENT# 7510760 CODE AREA la UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 'A c rP r,0 lASTE 1 SYSTEMS i COMPANY NAME TELEPHONE NUMBER CHCF-California Heath Care Facility (209) 467-4661 ADDRESS cc O 7707 S. Austin Rd Stockton, CA 95215 I certify that the information provided is true and correct, and that the generated materials are properly classified, described, z packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the LU U.S. Department of Transportation. // Able G. s 1 0-31-2024 12:17 PM NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Anthony Jenkins AJ 5039 COMPANY NAME TELEPHONE NUMBER w Med-Waste Systems, LLC (818) 998-5533 F- cc ADDRESS DATE MEDICAL WASTE COLLECTED CL d 4882 McGrath St Suite 320 Ventura, CA 93003 10-31-2024 12:17 PM z Pharm waste 8 gallon Pharm waste 2 gallon Q X cont. wt.X X cont. wt.X N cant, wt.X q cont. wt.p X Cont. wt.q cc 5 64 1 3 F- >- I certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load. I am aware that falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. a Anthony Jenkins 10-31-2024 12:17 PM NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER N NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER w F- O COMPANY NAME TELEPHONE NUMBER a to Z Q ADDRESS DATE MEDICAL WASTE COLLECTED F- Z [_] p cool. wt.p p coot. vR,q p cool. wt.N q coot. wt,p p Cont. vd.p Q N I certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load. I am aware that Cr w falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. U_ V) Z Cr 1— NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE r COMPANYNAME TELEPHONE NUMBER Healthwise Services (559) 834-3333 J U ADDRESS < 4800 E Lincoln Ave Fowler CA 93625 °C PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED w U- TSOST-89 10-31-2024 3:02 PM 67.00 to Z Q DISCREPANCY INDICATION SPACE f— H w I certify that I have been authorized to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the requirements outlined in that authorization. F- w Jorge Ambriz ��— 10-31-2024 3:02 PM cc NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE In case of emergency, call ( 818 ) 998-5533 (24-hr company or other emergency response group telephone) Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations.